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1.

Study Objective

To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis.

Design

Video case

Setting

Teaching hospital (Canadian Task Force classification III).

Patients

One patient presenting deep and severe diaphragmatic endometriosis.

Intervention

Laparoscopic cure of diaphragmatic endometriosis.

Measurements and Main Results

Throughout this video, which was approved by the institutional board review, we demonstrate safe and complete surgical treatment of a patient suffering severe pelvic and diaphragmatic endometriosis. The patient complained of menstrual dyspnea and shoulder pain persisting despite hormonal treatment, associated with persistent dyspareunia and pelvic pain despite a previous laparoscopic surgery. Patient positioning and anesthesia were adapted to the special requirements of the surgical technique and the expected risks. The operation consisted of the exposure of the right diaphragm by mobilization of the liver, CO2 laser vaporization of left and right diaphragmatic lesions, nerve-sparing excision of infiltrating nodules, and pleural exploration. Finally, we performed an excision of pelvic endometriosis. Participation of 3 surgical teams to this procedure allowed a safe and complete laparoscopic treatment with resolution of pain symptoms at a 1- and 3-month follow-up.

Conclusion

Laparoscopic treatment allows a safe and complete treatment of diaphragmatic endometriosis.  相似文献   

2.

Study Objective

To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain.

Design

A prospective cohort trial (Canadian Task Force classification II). Evidence obtained from a well-designed cohort study.

Setting

A tertiary laparoscopic subspecialty unit in Melbourne, Australia.

Patients

Fifty-seven patients undergoing laparoscopy for the investigation of pelvic pain were recruited. Fifty-three patients were eligible for analysis.

Interventions

Patients underwent standard white-light laparoscopy of the pelvis followed by NBI survey to assess for any additional areas suspicious for endometriosis.

Measurements and Main Results

All identified areas of possible endometriosis were resected and sent for blinded histopathological analysis. The additional predictive value of NBI was 0% if the preceding white-light survey was negative and 86% if the preceding white-light survey was positive.

Conclusion

The use of NBI at laparoscopy for the investigation of pelvic pain is beneficial in finding additional areas of endometriosis if endometriosis is already suspected after white-light survey in a tertiary laparoscopic unit. Further research in nonspecialized units may show additional benefit and requires further research. NBI may also be useful as a diagnostic aid for trainees.  相似文献   

3.

Study Objective

To examine the potential beneficial effect of platelet-rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion.

Design

A single-blind, randomized study (Canadian Task Force classification I).

Setting

A certified animal research facility.

Animals

Thirty female Sprague-Dawley rats.

Interventions

Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment; PRP (group 1, n?=?10), fibrin sealant (group 2, n?=?10), or no agent (group 3, n?=?10) was applied after shaving of the endometriotic nodule (second surgery).

Measurements and Main Results

Colonic endometriosis was successfully induced in all subjects. Four days after the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in a significantly higher expression in both the PRP and fibrin sealant groups (p?=?.011 and p?=?.011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p?=?.033), whereas greater new blood vessel formation was observed in the fibrin sealant group compared with the control (p?=?.023). No histologic evidence of residual or recurrent disease was detected.

Conclusion

Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting.  相似文献   

4.

Study Objective

To validate the preoperative ultrasound-based endometriosis staging system (UBESS) for predicting the correct Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and Australasian Gynaecological Endoscopy and Surgery (AGES) Society's level of laparoscopic skill required for endometriosis surgery.

Design

Multi-center retrospective cohort study (Canadian Task Force classification II-2).

Setting

Tertiary teaching hospital and a private gynecologic clinic.

Patients

155 women presenting with chronic pelvic pain and/or a history of endometriosis.

Interventions

Women underwent detailed specialized transvaginal ultrasound (TVS) in a tertiary referral unit to diagnose and stage endometriosis using the 3 stages of the UBESS. The UBESS was correlated to RANZCOG/AGES laparoscopic skill levels. The UBESS classifications were correlated as follows: UBESS I to predict RANZCOG/AGES surgical skill level 1/2, UBESS II to predict RANZCOG/AGES skill level ¾, and UBESS III to predict RANZCOG/AGES skill level 6.

Main Results

The accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the UBESS I to predict the RANZCOG/AGES surgical skill levels 1/2 were 99.4%, 98.9%, 100%, 100%, 98.5%, not applicable, and .011; those of UBESS II to predict surgical skill levels 3/4 were: 98.1%, 96.8%, 98.4%, 93.8%, 99.2%, 60 and .033, respectively, and those for UBESS III to predict surgical skill level 6 were: 98.7%, 97.2%, 99.2%, 97.2%, 99.2%, 115.7, and 0.028, respectively. The rate of correctly predicting the exact level of skills needed was 98.1%, and Cohen's kappa statistic for the agreement between UBESS prediction and levels of training required at surgery was 0.97, indicating almost perfect agreement.

Conclusions

The UBESS can be used to predict the level of complexity of laparoscopic surgery for endometriosis based on the RANZCOG/AGES skills levels for laparoscopy. It now awaits external validation in multiple centers with various surgical skill level classification systems to assess its general applicability.  相似文献   

5.
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6.

Study Objective

To assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up.

Design

Prospective and multicenter cohort study (Canadian Task Force classification II-2).

Setting

Five districts including a tertiary referral center and private and general public hospitals.

Patient

Patients (n?=?981), aged 15 to 50years, underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012.

Intervention

Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included.

Measurements and Main Results

The mean visual analog scale score for dysmenorrhea fell from 5.3 ± 3.7 (time 0) to 2.6 ± 3.3 at 6 months, and 2.3 ± 3.3 at 36 months of follow-up (p <.001). Mean visual analog scale scores for chronic pelvic pain and dyspareunia fell from 2.6 ± 3.5 and 2.7 ± 3.2, respectively, before surgery to 1.4 ± 2.5 and 1.1 ± 2.2 at 6 months and then 1.3 ± 2.5 and 1.2 ± 2.3 at 36 months of follow-up. The Short Form 36-Item survey analysis revealed the greatest increases linked to physical domains (i.e., bodily pain and role limitations) from 54.6 ± .9 and 63.3 ± 1.3, respectively, at time 0 to 74.4 ± .9 and 81.9 ± 1.1 at 6 months of follow-up (p <.001), with scores subsequently remaining stable. Among mental domains the most favorable results involved social functioning and role limitations due to emotional problems, which increased from 66 ± .8 and 65.7 ± 1.3 at time 0 to 75.6 ± .9 and 77.4 ± 1.3 at 6 months of follow-up, respectively (p <.001), with scores remaining stable over time.

Conclusions

Surgical treatment of endometriosis improves pelvic and sexual pain postoperatively in many women with endometriosis. Improvement later plateaus and remains stable, allowing patients to experience the beneficial effects over a period of years.  相似文献   

7.

Objective

To review the evidence and provide an opinion as to whether universal cervical length screening to prevent preterm birth should be adopted across Canada.

Outcomes

Outcomes evaluated include prevention of preterm birth.

Evidence

Literature searches using Knowledge Finder, Medline and Cochrane databases were searched for articles published up to April 2018 on cervical length screening for prevention of preterm birth.

Values

The evidence obtained was reviewed and evaluated by the Diagnostic Imaging Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, and Costs

The prevention of preterm birth in a cost-effective manner is of significant importance to the health of mothers and their families. This committee opinion will summarize the current evidence for universal cervical length screening to prevent preterm birth in Canada, determine whether it meets the Junger and Wilson criteria for screening tests, and make recommendations as to its use in Canada.

Validation

These guidelines have been reviewed and approved by the Diagnostic Imaging Committee of the SOGC and The Society of Obstetricians and Gynaecologists of Canada (SOGC).

Sponsors

The Society of Obstetricians and Gynaecologists of Canada (SOGC).  相似文献   

8.

Study Objective

To evaluate serial generation of microparticles (MPs) after laparoscopic stripping or CO2 laser vaporization in the surgical treatment of patients with ovarian endometrioma (OE).

Design

A prospective, randomized, blinded, pilot study (Canadian Task Force classification I).

Setting

Tertiary care university hospital from December 2014 to July 2016.

Patients

Thirty women with unilateral OE undergoing laparoscopic surgery.

Intervention

Patients were randomly selected to undergo either CO2 laser vaporization (L group) or laparoscopic stripping (S group) of OE.

Measurements and Main Results

Blood samples were collected before surgery and at 2 hours, 24 hours, 1 month, and 3 months after surgery. An MP generation curve after OE surgery was created. MP generation was greater in the S group than in the L group at all time points evaluated. The MP generation curve showed a significantly higher area under the curve after excisional surgery (p <.05).

Conclusion

The higher MP levels in the S group suggest an increased inflammation and procoagulant response after this procedure.  相似文献   

9.

Study Objective

To evaluate the feasibility of an en-bloc salpingectomy at the time of vaginal hysterectomy for removal of Essure inserts.

Design

Prospective observational study (Canadian Task Force classification II-1).

Setting

Monocenter study at the Conception University Hospital Center, Marseille, France.

Patients

Women seeking removal of the Essure device and candidate for vaginal hysterectomy from January 1, 2017 to January 31, 2018.

Interventions

Patient underwent a total hysterectomy and bilateral salpingectomy by the vaginal route (VH-S) with en-bloc removal of each hemiuterus with the ipsilateral fallopian tube, thereby allowing for removal of the Essure inserts without fragmentation.

Measurements and Main Results

Twenty-six VH-S were performed. There was no converted case to laparoscopy or laparotomy because of issues regarding feasibility or complications. Removal of each hemiuterus with the ipsilateral tube as a single unit was feasible in all cases. There was 1 Clavien-Dindo grade 1 perioperative complication: a bladder injury that required 10days of urinary catheterization. There were 2 grade 2 postoperative complications: 1 case of metrorrhagia of a granuloma on the vaginal fundus that was treated with silver nitrate and 1 case of acute urinary retention that required urinary catheterization for 24hours.

Conclusion

Performing a VH-S with en-bloc removal of the hemiuterus with the ipsilateral tube without fragmentation orsectioning of the Essure inserts appears to be feasible. The vaginal route can hence be an approach for women who undergo hysterectomy during Essure insert surgery removal.  相似文献   

10.

Study Objective

To evaluate the long-term safety and efficacy of tension-free vaginal tape (TVT).

Design

Prospective observational study (Canadian Task Force classification II-2).

Setting

Tertiary referral center in China.

Patients

Between January 2004 and December 2005, 85 consecutive patients who underwent the TVT procedure were included. Patients with mixed incontinence or pelvic organ prolapse requiring surgery were excluded.

Interventions

TVT procedure.

Measurements and Main Results

The primary outcomes were long-term postoperative complications. The secondary outcomes included long-term subjective satisfaction (Patient Global Impression of Improvement), objective cure rate (stress test), quality of life, and sexual function. At the 13-year follow-up, 70 patients (82%) were available for evaluation. De novo overactive bladder was observed in 15.7% of patients, and voiding symptoms were found in 17.1% of patients. None of the patients reported voiding dysfunction that needed treatment with tape removal or catheterization. Tape exposure occurred in 2.9% of patients. The subjective satisfaction rate and objective cure rate were 78.6% and 81.4%, respectively.

Conclusion

TVT is a safe and effective treatment for stress urinary incontinence, even at the 13-year follow-up. The prevalence rates of overactive bladder and voiding symptoms are increased with advancing age and should not be considered long-term postoperative complications.  相似文献   

11.

Study Objective

To estimate the incidence of infection after diagnostic and operative hysteroscopic procedures performed in an in-office setting with different distension media (saline solution or CO2).

Design

Prospective, multicenter, observational study (Canadian Task Force classification II-2).

Setting

Tertiary women's health centers.

Patients

A total of 42,934 women who underwent hysteroscopy between 2015 and 2017.

Interventions

Of the 42,934 patients evaluated, 34,248 underwent a diagnostic intervention and 8686 underwent an operative intervention; 17,973 procedures used CO2 and 24,961 used saline solution as a distension medium. Patients were contacted after the procedure to record postprocedure symptoms suggestive of infection, including 2 or more of the following signs occurring within the 3 weeks after hysteroscopy: fever; lower abdominal pain; uterine, adnexal, or cervical motion tenderness; purulent leukorrhea; vaginal discharge or itchiness; and dysuria. Vaginal culture, clinical evaluation, transvaginal ultrasound, and histological evaluation were completed to evaluate symptoms.

Measurements and Main Results

Operative hysteroscopies comprised polypectomies (n?=?7125; 82.0%), metroplasty (n?=?731; 15.0%), myomectomy (n?=?378; 7.8%), and tubal sterilization (n?=?194; 4.0%). Twenty-five of the 42,934 patients (0.06%) exhibited symptoms of infection, including 24 patients (96%) with fever, 11 (45.8%) with fever as a single symptom, 7 (29.2%) with fever with pelvic pain, and 10 (41.7%) with fever with dysuria. In 5 patients with fever and pelvic pain, clinical examination and transvaginal ultrasound revealed monolateral or bilateral tubo-ovarian abscess. In these patients, histological examination from surgical specimens revealed the presence of endometriotic lesions.

Conclusion

The present study suggests that routine antibiotic prophylaxis is not necessary before hysteroscopy because the prevalence of infections following in-office hysteroscopy is low (0.06%).  相似文献   

12.

Study Objective

To point out the relevant anatomy of the ureter and to demonstrate its rules of dissection.

Design

An educational video to explain how to use ureteral relevant anatomy and the principle of dissection to perform safe ureterolysis during laparoscopic procedures.

Setting

A tertiary care university hospital and endometriosis referential center.

Interventions

Anatomic keynotes of the ureter and examples of ureterolysis.

Conclusion

This video shows the feasibility of laparoscopic ureteral dissection and provides safety rules to perform ureterolysis. Identification and dissection of the ureter should be part of all gynecologic surgeons’ background to reduce the risk of complications [1]. Knowledge of anatomy plays a pivotal role, allowing the surgeon to keep the ureter at a distance and minimizing the need for ureterolysis. Unfortunately, the need for ureteral dissection is not always predictable preoperatively, and gynecologic surgeons need to master this technique, especially when approaching more complex procedures such as endometriosis [2]. An implicit risk of damage cannot be denied when performing ureterolysis; therefore, the ureter should be dissected only when strictly necessary and handled with care to minimize the use of energy [3].  相似文献   

13.

Study Objective

To prospectively evaluate the mesh exposure rate after robot-assisted laparoscopic pelvic floor surgery for the treatment of female pelvic organ prolapse (POP) in a large cohort.

Design

Prospective observational cohort study (Canadian Task Force classification II-2).

Setting

Two large teaching hospitals with a tertiary referral function for pelvic floor disorders.

Patients

Patients with symptomatic POP and simplified POP quantification (S-POP) stage ≥2. Patients with a history of mesh repair or concomitant insertion of a tension-free vaginal tape were excluded.

Interventions

Robot-assisted laparoscopic sacrocolpopexy or robot-assisted laparoscopic supracervical hysterectomy with a sacrocervicopexy.

Measurements and Main Results

A blinded vaginal examination with the aid of a transparent speculum was performed to look for mesh-related complications. Mesh exposures were described following the International Urogynecological Association/International Continence Society classification system. One hundred and ninety-two patients were included, of whom 166 (86.5%) were seen for follow-up examination. The median duration of follow-up was 15.7 months (range, 8.2–44.4 months). Two vaginal mesh exposures (1.2%) were detected, both of which were treated in the outpatient clinic. One patient without any complaints had a suture exposure, which was removed in the outpatient clinic.

Conclusion

The safety of the use of mesh in pelvic floor surgery is a matter of debate owing to the occurrence of mesh-related complications. Based on the current literature, mesh-related complications seem to be lower in transabdominal mesh surgery than in transvaginal mesh surgery. In this study, a low mesh exposure rate was observed in robot-assisted abdominal pelvic floor surgery for POP.  相似文献   

14.

Study Objective

Evaluate the prevalence, trends, and outcomes of minimally invasive surgical (MIS) staging of malignant ovarian germ cell tumors (MOGCTs) apparently confined to the ovary.

Design

Retrospective cohort study (Canadian Task Force classification II-2).

Setting

Participating hospitals in the National Cancer Data Base.

Patients

Women diagnosed between 2010 and 2014 with a MOGCT apparently confined to the ovary with information on the planned surgical approach.

Interventions

Staging with MIS or laparotomy.

Measurement and Main Results

A total of 918 patients were identified. MIS was planned for 294 patients (32%): a laparoscopic approach for 237 patients and a robotic-assisted approach for 57 patients. Rate of conversion to laparotomy was 11% (46 cases), 1.7% and 15.6% in the robotic and laparoscopy groups, respectively (p?=?.003). No difference in the use of MIS was noted based on year of diagnosis (p?=?.38). By multivariate analysis white race, higher level of education, and smaller tumor size were associated with the receipt of MIS. Patients in the MIS group were less likely to undergo lymph node dissection (39.6% vs 51.3%, p?=?.001) and omentectomy (18.7% vs 28.5%, p?=?.002). Hospital stay after surgery was shorter for patients who had MIS (median, 2 vs 3 days; p <.001). Unplanned 30-day readmission rate was also lower in the MIS group (1.4% vs 3.9%, p?=?.043). No difference in overall survival was noted between the 2 groups (p?=?.81).

Conclusion

MIS for apparent early-stage MOGCTs was less comprehensive but associated with a decreased hospital stay and unplanned readmission rate.  相似文献   

15.

Study Objective

To show laparoscopic management of an arteriovenous malformation in a patient with deep pelvic endometriosis

Design

A step-by-step explanation of the surgery using an instructive video.

Setting

Hautepierre University Hospital, Strasbourg, France.

Interventions

We describe the case of a 37-year-old patient presenting with deep pelvic endometriosis and a uterine arteriovenous malformation. Deep pelvic endometriosis was diagnosed during a tubal ligation in 2015. Laparoscopy also showed some pelvic varicosities. Hysteroscopy was performed to increase the diagnostic precision. Huge blood vessels with an arterial pulse on the anterior wall of the uterus were found. The endometriosis of the patient was very symptomatic; she suffered from dysmenorrhea, menorrhagia, intense dyspareunia, and dyschezia. Magnetic resonance imaging indicated a large arteriovenous shunt in the anterior part of the uterus and bladder endometriosis. After a pluridisciplinary medical staff meeting, we decided to begin treatment with luteinizing hormone-releasing hormone analogs. Then, she underwent embolization of the arteriovenous malformation, which produced regression of the lesions as indicated by reevaluation with magnetic resonance imaging. We decided to perform laparoscopic hysterectomy. Evaluation of the abdominal cavity showed diaphragm endometriosis, deep pelvic endometriosis, and the arteriovenous malformation. We started with left ureterolysis and opening of the rectovaginal septum. After that, we radically dissected the left side of the uterus with a left oophorectomy and then the right side, conserving the ovary. Then, we shaved the bladder for endometriosis removal. To finish, we performed a right salpingectomy with a right ovariopexy, vaginal closure, and coagulation of the diaphragm's nodules. The patient agreed to record and publish the surgery, and the local institutional review board gave its approval.

Conclusion

To conclude, preoperative embolization of the arteriovenous shunt improves surgery, avoiding excessive bleeding and permitting easier radical hysterectomy for deep pelvic endometriosis. Similar cases have been published [1], but to our knowledge, our video is the first regarding this subject. It appears that embolization can fail, but hysterectomy remains the gold standard treatment [2].  相似文献   

16.

Study Objective

Minimally invasive surgical procedures have shown significant improvement over the last 20 years. Today, nearly half of the surgeries, including oncology, are performed with minimally invasive methods. In obstetrics and gynecology surgery practice, laparoscopy can now be used in almost all operations. In this video, we performed a laparoscopic evacuation of a 12-week missed abortion case like a cesarean section at the time of bilateral salpingectomy.

Design

A case report (Canadian Task Force classification III).

Setting

A tertiary referral center in Bursa, Turkey.

Patient

A 38-year-old patient.

Intervention

Laparoscopic evacuation of the pregnancy product (like a cesarean section) and bilateral salpingectomy. The local institutional review board approved the video.

Measurements and Main Results

Gravida: 4, parity: 3. The patient was in the 12th week of her gestation when we diagnosed a missed abortion. In situs of the operation, there was a 12-week pregnancy filling the pouch of Douglas. We clipped the uterine arteries bilaterally and retracted the bladder flap to create a safe surgical incision in the low anterior segment of the uterus. We used the monopolar cautery to incise the uterus from superior to inferior similar to the low vertical classic uterine incision in the cesarean section. The abortus material was removed with the laparoscopic endobag, and bilateral salpingectomy was performed.

Conclusion

Developments in minimally invasive surgery are progressing day by day. As advances in laparoscopic and robotic surgery progress, complicated surgical procedures would be done efficiently.  相似文献   

17.

Study Objective

To evaluate the safety and effectiveness of hysteroscopic myomectomy after uterine artery embolization (UAE) for the treatment of large-sized submucosal myomas with deep intramural invasion that are difficult to treat with 1-step hysteroscopy.

Design

A retrospective cohort study (Canadian Task Force classification II-2).

Setting

An academic university hospital.

Patients

Eight premenopausal patients with symptomatic submucosal myomas with intramural invasion.

Interventions

All of the patients after bilateral UAE underwent subsequent hysteroscopic operation 3 to 15 months after UAE.

Measurements and Main Results

A total of 8 patients who had a large-sized submucosal myoma with deep myometrial invasion were included. The average volume of the submucosal myomas was 87.7±39.9 cm3 as confirmed by magnetic resonance imaging, and the average patient age was 37.6 years. The mean volume reduction of the submucosal myomas was 83.3±16.4% after UAE, and no immediate complications were observed. One-step hysteroscopic myomectomy after UAE was successfully performed in all patients. Leiomyomas with hyaline degeneration were pathologically confirmed. All women showed improved symptoms, and there was no evidence of recurrence 1 year later. One patient conceived naturally and delivered a full-term baby.

Conclusion

In premenopausal women with large-sized symptomatic submucosal myomas with deep myometrial invasion, hysteroscopic myomectomy after UAE is very effective and safe.  相似文献   

18.

Study Objective

To compare the number of days required to return to daily activities after laparoscopic hysterectomy with 2 tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes were additional measures of patient recovery, perioperative outcomes, containment bag integrity, and tissue spillage.

Design

Multicenter prospective cohort study and follow-up survey (Canadian Task Force classification II-2).

Setting

Two tertiary care academic centers in northeastern United States.

Patients

Seventy women undergoing laparoscopic hysterectomy with anticipated need for manual morcellation.

Interventions

Tissue extraction by either contained minilaparotomy or contained vaginal extraction method, along with patient-completed recovery diary.

Measurements and Main Results

Recovery diaries were returned by 85.3% of participants. There were no significant differences found in terms of average pain at 1, 2, or 3 weeks after surgery or in time to return to normal activities. Patients in both groups used narcotic pain medication for an average of 3 days. After adjusting for patient body mass index, history of prior surgery, uterine weight, and surgeon, there were no differences found for blood loss, operative time, length of stay, or incidence of any intra- or postoperative complication between groups. All patients had benign findings on final pathology. More cases in the vaginal contained extraction group were noted to have bag leakage on postprocedure testing (13 [40.6%] vs 3 [8.3%] tears in vaginal and minilaparotomy groups, respectively; p?=?.003).

Conclusion

Regarding route of tissue extraction, contained minilaparotomy and contained vaginal extraction methods are associated with similar patient outcomes and recovery characteristics.  相似文献   

19.

Study Objective

We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions.

Design

Retrospective multi-institution cohort (Canadian Task Force classification II-2).

Setting

Three tertiary cancer referral cancer centers.

Patients

Patients with endometrial and vulvar cancer undergoing lymph node evaluation.

Interventions

Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment.

Measurements and Main Results

Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins.

Conclusions

Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.  相似文献   

20.

Study Objective

To evaluate the effect of intraoperative superior hypogastric blocks on postoperative pain management.

Design

Prospective observational cohort study (Canadian Task Force classification II-2).

Setting

Kocaeli Derince Training and Research Hospital, University of Health Sciences, Department of Anesthesiology and Reanimation, Department of Gynecology and Obstetrics, Kocaeli, Turkey.

Patients

Sixty female patients who underwent elective laparoscopic hysterectomy were included in this study. Patients were divided into 2 groups: those who had intraoperative superior hypogastric plexus (SHP) block (Hypo; n?=?30) and those who did not have intraoperative SHP block (No-Hypo; n?=?30).

Interventions

Intraoperative SHP blocks were performed with the modified laparoscopic technique previously described by us.

Measurements and Main Results

Rescue analgesic time was calculated in minutes as the time interval between the last administration of analgesic in the operating room or postanesthesia care unit and the first analgesic demand in the surgical ward. Rescue analgesic times were found to be significantly higher in the Hypo group. Nonsteroidal anti-inflammatory drugs and opioid requirements in the postanesthesia care unit and in the surgical ward were significantly lower in the Hypo group. There was no difference between groups in postoperative nausea and vomiting.

Conclusions

Intraoperative SHP block is a preferable modality for postoperative analgesia in patients undergoing hysterectomy. The surgical laparoscopic modified anterior approach we describe is an uncomplicated and easily applicable method. More effective results would be seen if used together with wound site local anesthetic infiltration or abdominal wall plane blocks. (Clinical trial registration no. NCT03427840.)  相似文献   

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